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Hawthorn Drive Surgery Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 19 November 2018

This practice is rated as Requires Improvement overall. (Previous rating published 10 August 2017 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Hawthorn Drive Surgery on 9 October 2018. The practice was previously inspected on 14 November 2016 and was rated as inadequate for providing safe, effective and well led services, requires improvement for providing caring services and good for providing responsive services. Overall the practice was rated as inadequate. As a result of the findings on the day of the inspection, the practice was issued with a warning notice on 13 December 2016 for regulation 17 (good governance). They were also given a requirement notice for regulation 12, safe care and treatment. The practice was placed into special measures for six months. A focussed inspection was undertaken on the 16 February 2017, to check on improvements detailed in the warning notice issued on 13 December 2016, following the inspection on 14 November 2016. They had complied with the warning notice. A comprehensive inspection was undertaken on 17 July 2017. The practice was rated good overall and good for all domains with the exception of effective, which was rated requires improvement. The practice was taken out of special measures. This inspection was undertaken to check that improvements had been sustained because the practice had gone from being in special measures to being rated good overall.

At this inspection we found:

  • There was an effective system for recording and reporting of significant events and complaints. A process for sharing of learning and ensuring that actions had been completed had been established and this was embedded.
  • Systems were in place to keep people safe, however they were not always followed. The practice were not able to evidence that three clinicians and one non-clinician had a Disclosure and Barring Service (DBS) check completed by the practice, or assurance from NHS England, that an appropriate DBS had been completed. References had not been obtained for two nurses before they commenced employment at the practice. The vaccination history of staff had not been obtained, except for Hepatitis B status. A process was not in place to check the professional registration of staff on an ongoing basis. Following the inspection, the practice advised that they had established a system to check this.
  • Training which was deemed mandatory had not been completed by all staff. This included training for safeguarding children and vulnerable adults, basic life support, infection control and fire safety.
  • Arrangements were in place for infection prevention and control, however the checks of daily cleaning completed by clinical staff were not always completed. The practice’s policy advised that sharps boxes should be changed every three months. We found one sharps box which was dated April 2018 and one sharps box which had not been dated.
  • An effective system was in place to review and act on safety alerts and this had been embedded.
  • Some improvements had been made to ensure patients were coded according to their diagnosis and that treatment was appropriate. A system of recall for patients who required monitoring had been embedded which included the implementation of a lead GP, other clinical staff and administration support. However, the practice’s performance on quality indicators for people with long term conditions, for example diabetes and COPD was significantly lower than the CCG and England averages. They also had a significantly higher than average exception rate for five of the seven QOF mental health indicators.
  • Patients diagnosed with cancer were not all reviewed appropriately and only 18 out of 66 patients with a learning disability had received a health review.
  • The practice undertook audits, for example to identify areas of patient need, and to monitor workload to inform appropriate staffing levels. There was evidence of clinical audit, with some two cycle audits which had a positive impact on the quality of care for patients.
  • The practice worked with external agencies and services to meet the needs of patients. Social services and the Citizens Advice Bureau (CAB) held a drop-in clinic at the practice every week. Multidisciplinary meetings were held, minuted and actions from these had been documented in the patient’s medical record. However, not all patients diagnosed with cancer had been reviewed.
  • Staff involved and treated patients with compassion and kindness. Patients said they were treated with dignity and respect and were involved in their care and decisions about their treatment
  • In general, patients found the appointment system easy to use and reported that they could access care when they needed it.
  • Staff reported they were supported by the management team and were happy to work in the practice.
  • Leaders had the capacity and skills to deliver high-quality, sustainable care, however effective systems were not always in place to ensure this was provided.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider


make improvements are:

  • Review and improve systems for managing infection prevention and control, particularly the management of sharps boxes and the documentation of in house cleaning.
  • Continue to develop the system to include the review of patients who are identified as being frail.
  • Complete the hard wiring test of the premises.

Professor Steve Field


Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection areas


Requires improvement


Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement